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psnet.ahrq.gov/perspective/conversation-timothy-b-mcdonald-md-jd
February 26, 2025 - In Conversation With… Timothy B. McDonald, MD, JD
April 1, 2019
Citation Text:
In Conversation With… Timothy B. McDonald, MD, JD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/web-mm/may-i-have-another-medication-error
March 01, 2009 - May I Have Another?—Medication Error
Citation Text:
Wolf MS. May I Have Another?—Medication Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/perspective/conversation-withbarbara-blakeney-ms-rn
August 01, 2005 - In Conversation with…Barbara A. Blakeney, MS, RN
August 1, 2005
Also Read an Essay
Citation Text:
In Conversation with…Barbara A. Blakeney, MS, RN. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Ser…
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psnet.ahrq.gov/perspective/conversation-thomas-j-nasca-md-macp
July 10, 2024 - In Conversation With… Thomas J. Nasca, MD, MACP
April 1, 2016
Citation Text:
In Conversation With… Thomas J. Nasca, MD, MACP. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/web-mm/blind-spot
July 30, 2020 - Blind Spot
Citation Text:
Lee LA. Blind Spot. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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psnet.ahrq.gov/web-mm/missing-abscess-radiology-reads-digital-era
January 01, 2009 - SPOTLIGHT CASE
The Missing Abscess: Radiology Reads in the Digital Era
Citation Text:
Siegel EL. The Missing Abscess: Radiology Reads in the Digital Era. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/web-mm/deaths-not-foretold-are-unexpected-deaths-useful-patient-safety-signals
March 01, 2004 - Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals?
Citation Text:
Shojania KG. Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/web-mm/aspergillus-mediastinitis-endocarditis-pediatric-patient-complicating-cardiac-surgery-and
November 16, 2022 - Aspergillus Mediastinitis & Endocarditis in a Pediatric Patient Complicating Cardiac Surgery and Bedside Chest Closure.
Citation Text:
Partridge E, Dodson D, Reilly M, et al. Aspergillus Mediastinitis & Endocarditis in a Pediatric Patient Complicating Cardiac Surgery and Bedside Chest Closure.. PSNet [inter…
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psnet.ahrq.gov/node/74713/psn-pdf
January 26, 2022 - Patient Safety Events Involving Opioid Dose Stacking
January 26, 2022
Porras H, Lammers C. Patient Safety Events Involving Opioid Dose Stacking. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/patient-safety-events-involving-opioid-dose-stacking
Disclosure of Relevant Financial Relationships: As a provider ac…
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psnet.ahrq.gov/web-mm/moving-pains
August 17, 2017 - SPOTLIGHT CASE
Moving Pains
Citation Text:
Schell H, Wachter R. Moving Pains. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/web-mm/out-sight-out-mind-out-office-test-result-management
September 01, 2007 - SPOTLIGHT CASE
Out of Sight, Out of Mind: Out-of-Office Test Result Management
Citation Text:
Poon EG. Out of Sight, Out of Mind: Out-of-Office Test Result Management. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
…
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psnet.ahrq.gov/web-mm/hidden-mystery
December 01, 2011 - SPOTLIGHT CASE
Hidden Mystery
Citation Text:
Brunette DD. Hidden Mystery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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psnet.ahrq.gov/node/846170/psn-pdf
March 15, 2023 - Duplicate Therapies in Retail Pharmacy
March 15, 2023
Punatar N, Molla M, Lee S. Duplicate Therapies in Retail Pharmacy. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/duplicate-therapies-retail-pharmacy
The Cases
Case 1: A middle-aged man with a past medical history of heart failure with reduced ejection f…
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psnet.ahrq.gov/perspective/unfinished-patient-safety-agenda
August 01, 2005 - The Unfinished Patient Safety Agenda
Linda H. Aiken, PhD, RN | August 1, 2005
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Aiken LH. The Unfinished Patient Safety Agenda. PSNet [internet]. Rockville (MD): Agency for Healthc…
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psnet.ahrq.gov/web-mm/transfer-troubles
December 29, 2014 - SPOTLIGHT CASE
Transfer Troubles
Citation Text:
Hains IM. Transfer Troubles. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/node/33771/psn-pdf
August 22, 2014 - Beyond the Hospital: the New Frontier of Patient Safety
August 22, 2014
Plews-Ogan M. Beyond the Hospital: the New Frontier of Patient Safety. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/beyond-hospital-new-frontier-patient-safety
Perspective
The frontier of patient safety outside the hospital has y…
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psnet.ahrq.gov/node/49522/psn-pdf
November 01, 2006 - Getting a Good Report Card: Unintended Consequences
of the Public Reporting of Hospital Quality
November 1, 2006
Lindenauer PK. Getting a Good Report Card: Unintended Consequences of the Public Reporting of
Hospital Quality. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/getting-good-report-card-unintended-…
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psnet.ahrq.gov/perspective/conversation-karl-bilimoria-md-ms
April 19, 2023 - In Conversation With… Karl Bilimoria, MD, MS
August 1, 2017
Citation Text:
In Conversation With… Karl Bilimoria, MD, MS. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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…
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psnet.ahrq.gov/node/50611/psn-pdf
October 30, 2019 - The Lost Start Date: an Unknown Risk of E-prescribing
October 30, 2019
Wright A, Schiff G. The Lost Start Date: an Unknown Risk of E-prescribing. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/lost-start-date-unknown-risk-e-prescribing
Case Objectives
List the most common errors associated with computerized…
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psnet.ahrq.gov/node/49519/psn-pdf
September 01, 2006 - Triple Handoff
September 1, 2006
Vidyarthi A. Triple Handoff. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/triple-handoff
Case Objectives
Appreciate the prevalence of handoffs and sign out related errors.
Understand the key elements of a safe and effective written and verbal sign out.
List Kotter’s 8 st…